LAX04FA205 · Piper PA-44-180
Pan Am International Flight Academy Piper PA-44-180 · Accident: in flight collision with terrain/water en route
From Phoenix Deer Valley Airport (KDVT) to McClellan-Palomar Airport (KCRQ)
Event
- NTSB case
- LAX04FA205
- Event typeAccident: someone killed or seriously injured, or the aircraft substantially damaged (NTSB definition). Incident: an occurrence that affected or could have affected safety, short of that. Glossary
- Accident
- InvestigationHow far the investigation had got when the record was published: preliminary, ongoing, final or completed. Unknown where the source does not say. Glossary
- Completed
- API-reported fatalities
- 2 · all aircraft and ground
- Ground fatalities
- Unknown
- OperationWhat kind of flying it was, grouped by the rules it flew under: airline (US Part 121), air taxi and commuter (Part 135), general aviation (Part 91 and similar), military or government. Glossary
- General aviation
- WeatherVisual meteorological conditions (VMC): good enough to fly by looking outside. Instrument conditions (IMC): cloud or low visibility, flying by instruments. Glossary
- Visual Meteorological Cond
Piper PA-44-180
- Aircraft type
- Piper PA-44
- Category
- Airplane
- RegistrationThe aircraft's tail number, such as N12345 or G-ABCD. Registrations are reissued, so the same one years apart can be a different aircraft. Glossary
- N304PA
- Onboard fatalities
- Unknown
- Route
- From Phoenix Deer Valley Airport (KDVT), Phoenix, AZTo McClellan-Palomar Airport (KCRQ), Palomar, CA
- Aircraft age
- Not recorded
- Flight rulesThe regulations the flight operated under: in the US, Part 91 (general aviation), Part 121 (airlines), Part 135 (air taxi and commuter) and others; for flights abroad, the NTSB's coarser commercial or non-commercial code. Glossary
- Part 91: General Aviation
- Phase of flightThe stage of the flight when things started to go wrong: standing, taxi, takeoff, initial climb, en route, maneuvering, approach or landing. Glossary
- En route · cruise
- First occurrenceThe single coded event the NTSB judges best describes what happened (records from 2008 on). Older records name the first occurrence in the sequence instead. Glossary
- In flight collision with terrain/water
- DamageDestroyed: beyond practical repair. Substantial: damage that affects the structure, performance or handling and normally needs major repair. Minor: less than that. Glossary
- Destroyed
Cause areas
- Atc personnel(dep/apch) › Atc clearance, improper
- Flightcrew › Atc clearance, not verified
Approximate · Coordinates from the NTSB case API, which marks them as estimated or does not say; no uncertainty radius is established.
NTSB narrative
The twin engine airplane collided with rising mountainous terrain while in cruise flight on an IFR clearance. The airplane, N304PA, was on a night IFR flight and was number four in a trail of five company airplanes flying the same route. The time separation between each airplane was about 5 to 10 minutes. The airplane directly ahead of N304PA was N434PA. After being handed off from Los Angeles Center, the flight crew of N304PA contacted the TRACON sector controller at 2043:48 PDT, reporting level at 8,000. The TRACON sector controller instructed the pilot to fly heading 260 after the Julian VOR and intercept the localizer. At 2045:47, the TRACON sector controller told the pilot of N434PA to descend to 6,000 feet. The pilot of N434PA acknowledged the clearance. At 2047:55, the sector controller transmitted, "Seminole four papa alpha descend and maintain five thousand two hundred." The pilot of N304PA responded, "Down to five thousand two hundred for three zero four papa alpha." According to information provided by the TRACON sector controller, this clearance was intended for N434PA. The controller did not recognize that the clearance had been acknowledged by N304PA rather than N434PA. At 2049:55, the pilot of N304PA reported that he had ATIS information Zulu and the sector controller responded, "Seminole three zero four papa alpha thank you very much." At that time the data block on the TRACON controller's display was showing N304PA descending through about 6,600 feet. The Minimum Enroute Altitude for the airway segment being flown was 7,700 feet. At 2050:27, the sector controller again cleared N434PA to descend and maintain 5,200 feet. A Minimum Safe Altitude Warning (MSAW) alert on N304PA was presented to the Center controller at 2049:03. The aircraft's data block remained on the Center controllers display until the radar controller forced it off at 2050:07. The Center controller did not notify the TRACON sector controller that he was receiving a MSAW alert as required by FAA directives. The TRACON's MSAW system generated two predicted altitude alerts on the accident airplane at 2050:46 and 2050:51. According to FAA MSAW documentation, two consecutive predicted alerts will initiate an MSAW warning to the controller working the affected aircraft. Collectively, these alerts would have caused a 5 second aural alert to the sector controller beginning at 2050:51, along with a flashing red "LA" in N304PA's data block from 2050:51 until about 2051:06. The aircraft then descended below radar coverage, the track went into coast status, and the alert terminated. The wreckage of N304PA was located on a ridgeline 200 yards south of the Julian VOR at 5,537 feet msl. No preimpact airplane mechanical anomalies were identified.
Probable cause
The incorrect use of an abbreviated callsign by the TRACON sector radar controller to issue a descent clearance to N434PA and the sector controllers failure to detect that the clearance had been read back with the full callsign by the pilot of N304PA. Also causal was the pilots failure to question a clearance that descended them below the published Minimum En route Altitude (MEA). Contributing to the accident was the failure of both the Center and TRACON controllers to properly respond to the aural and visual Minimum Safe Altitude Warning System (MSAW) alert.
Verbatim NTSB analysis and probable cause from the NTSB dataset
Sources
NTSB record LAX04FA205
- Event ID
- 20040522X00629
- Case number
- LAX04FA205
- Dataset
- historical-pre2008
- Source SHA-256
- 89e2df6d848e7ab3b42e7d7c7a03ff403303057a26ca04c95b3ea67201c3ce74
Source notes (4)
- Unreviewed is an editorial label, not an investigation status. API-sourced is not report-checked or human-reviewed. Explicit event totals are used without summing aircraft injury tables; onboard allocation is withheld. Unknown values remain unknown. The operation category is mapped from the NTSB-reported FAR part and has not been reviewed.
- Filled from the NTSB case API where the bulk record had no value: local date, investigation status, coordinates. Values present in the bulk record are kept.
- The date is the local date; the NTSB stores the UTC date 2004-05-11.
- API snapshot SHA-256: 3f603e9f89d895476325d2a7a8f500d7ddfb77cafb3324edd792ef7bd149d46e; retrieved 2026-09-20T18:29:14.141Z.